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  • Clinical Ethics and the Culture of Conflict
  • Jacquelyn Slomka (bio)

The treatment of serious illness is often the occasion for conflict. Traditionally, discord between patient (or family) and physician has been resolved within the doctor-patient relationship, or when the patient chooses another physician. But as medical care and its social context have changed over the past decade, these strategies have become harder to use. Absent a reliable mechanism within the health care system to deal with conflicts, a new quasi-professional has emerged in the form of the bioethics consultant—or, in Nancy Dubler and Carol Liebman's model, the bioethics mediator.

In Bioethics Mediation: A Guide to Shaping Shared Solutions, Dubler and Liebman apply a mediation framework to resolve disputes among health care professionals, patients, and families in the clinical environment. The authors present their work as a guide to "help those training for (bioethics) consultation to acquire the interpersonal and process skills that are assumed to be part of the Core Competencies for Health Care Ethics Consultation (American Society for Bioethics and Humanities, 1998)" (p. xiii). Since few bioethics consultants have shared what exactly happens in an ethics consultation, the authors are to be commended for their willingness to describe the process and to critique their own work. Apart from its intended training function, this book provides a window into the process of bioethics consultation/mediation and a reference point for examining, in a global sense, some of the wider social and cultural implications of bioethics consultation as a means of conflict resolution in the clinical setting.

Ever since bioethics consultation was formally defined through the creation of the Society for Bioethics Consultation in 1986, the specialty of bioethics consultation has continued to evolve. The process seemed to work. With the help of the bioethics intermediary, there was a sense that frustrated physicians and nurses usually felt better, families were often mollified, and anger was defused. The "bioethics consultant" was promoted as a specialist in helping to resolve clinical dilemmas, framed as "ethical" because they often involved decisions with moral dimensions—for example, treatment decisions for patients at the end of life, disclosure of information, or confidentiality. But as Dubler and Liebman note (and as many bioethics consultants quickly realized), most of these "dilemmas" were not about ethical or moral differences. What were framed as "ethical dilemmas" more often were differences and misunderstandings grounded in poor communication between the medical team and families, in simple power struggles, or in disputes over real or perceived inequities in access to health care.

By applying mediation techniques to bioethics consultation, Dubler and Liebman take bioethics consultation to another level—defining a model process for it. They seek to adapt and make explicit a formal method developed from the "alternative dispute resolution movement" that has historically been used by community action groups for dealing with conflicts at the local political level and by the courts for "docket management"—the resolution of cases outside the court system (p. 8). Because Dubler and Liebman view clinical conflicts as mirroring other kinds of societal conflicts, they believe a mediation model for dispute resolution holds promise. Bioethics consultants will recognize many aspects of mediation as what they implicitly do in their work. The authors view bioethics consultation as "more authoritarian and hierarchical" and mediation as "more inclusive and empowering" (p.14), but they also use the concepts interchangeably at times.

Whether a mediation model can improve bioethics consultation for conflict resolution in the clinical setting remains to be seen, as little is known about the actual practice of bioethics consultation. A few have tried to rigorously evaluate the outcomes of bioethics consultation, but their studies suggest the difficulty in subjecting a complex social process to scientifically sound validation. Ironically, bioethics consultation has become one of the many processes widely adopted within health care with little unbiased evidence about its outcomes.

As described by Dubler and Liebman, several aspects of bioethics mediation are disquieting. One such aspect is the application of the legalistic framework of mediation to medical-ethical decisionmaking—not a surprising choice of paradigm, as both authors are trained in law. The problem is that legal disputes are adversarial by nature. The image of...

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